Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

a new day
-
2016 is literally around the corner, leaving me with 18 months to
retirement. Its with a mixture of trepidation, expectation and hope that I
turn the page....

1 year ago

Monday, May 10, 2010

The Pleasure Palace...Adults Only

I’ve noted before in this blog that the ED is a great place to restore your belief in love. Just when you think you’re terminally single and can never be wanted by anyone, you see couples in the ED that truly prove there’s someone for everyone, regardless of race, religion, ethnicity, dental health, hygiene, or tonnage. Young love is most often on display, either in the form of couples canoodling on the exam bed (especially true when the vomiting party is sharing potato chips with their beloved) or when an unexpected new pregnancy is discovered.

But, as Whitney Houston reminds us, learning to love yourself is the greatest love of all.

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Mr. Conrad was brought in by the ambulance because four days ago he had bent over to pick something up and had hurt his back. His pain was so incapacitating that he had managed to walk to a pay phone in order to call the ambulance. When I went to see him, however, the room was darkened and the privacy curtain pulled; and the expression on his face was not one of pain, but of ecstasy. Using my acute powers of observation and years of clinical training, I quickly deduced that it had something to do with the fact that his pants were unzipped and his hand tucked inside his wasteband, with a rhythmic motion to his right arm not unlike a focal seizure.

“Are you having a seizure?”

Startled, he looked up at me from the bed.

“Huh?”

“A seizure. Are you having a seizure?

“No.”

“Are you sure you’re not having a seizure? I ask because your arm is going back and forth like you might be having a seizure.”

I will hand it to Mr. Cooper; he was a quick thinker. “I’m holding in my hernia.”

That was a good answer, but not one above reproach. While I’ve never had a hernia myself, I’ve seen plenty of them. When someone has a hernia, they may sometimes support their scrotum with their hands, lifting the sac in order to prevent further discomfort (Please, no jokes about not being an athlete, but always being an athletic supporter. Thank you). But usually this is not a particularly rhythmic, or pleasurable, thing to do.

“Well, let’s check that out while we work on your back pain.”

So I did, and found no evidence of a hernia. He said, “I only see it when I sit up.” So I sat him up, and there was still no hernia. “I REALLY see it when I stand up and cough. But I can’t do that because I have back pain.”

Call me inherently suspicious, but I generally believe that if you’re able to walk to the pay phone you can stand up in the ED. So I made him stand up and cough. And still no hernia. He look puzzled.

“Hmm. It’s usually there.”

“I’m sure it will be there again soon,” I reassured him. Because a man has needs, don’t you know.

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Mr. Cooper reminded one of our nurses of a rotund African-American woman she had cared for last week who had taken similar liberties with her own contentment in the ED. When caught in the act and informed that this was perhaps inappropriate behavior for the health care setting, she said, “This is an EMERGENCY Room, and I’m gonna take care of my EMERGENCY.” She then proceeded to the restroom to relieve her emergency condition. At least it was assumed that she did, if the noises that were heard coming from the water closet by the nurse…and the rest of the ED…were any kind of reliable indication.

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About a year ago, the police brought us an intoxicated man who had been found in the public forum. His care was pretty routine…exam, blood tests, an intravenous alcohol “rally pack”… until one of the nurses came to me and ask me to make him cease his onanistic practices in the exam room.

Having reached deep into my soul for any latent Puritanism, I adopted the sternest visage possible when dealing with a scenario with the possibilty of reducing this seasoned professional to a giggling eight-year-old, and entered the room. There he was, eyes open, looking right at me, and continuing to raise his own personal flag in a most diligent, dedicated, and patriotic fashion.

“You know, you’ve really got to stop that. Makes the nurses nervous.”

He looked up at smiled, a broad grin highlighting his remaining teeth. He continued to hoist his banner.

“No, really, I’m serious. It’s inappropriate, and that kind of behavior will get you thrown out of here. Sleeping in the street isn’t worth getting off, right?”

”Hmm-hmmm.” Too deep into his patriotism to hear me.

I left the room, shaking my head. There is only so much you can do as a physician. You can provide the best counsel ever, but it’s up to the patient to act on your good advice. And clearly this man was getting a second, five-inch opinion.

“Did you get him to stop?’ asked the nurse.

I shook my head. “Nope, he’s still at it. But,” I added in a moment of reflection, “I’m not sure if I should be upset that my authority meant nothing, or feel proud that I’m such a sexy guy that he sped up when I was there.”

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I mentioned breaking down like an eight-year old when presented with funny conditions just below the beltline. No matter how much you’ve been in this business, that feeling never goes away. This is why I’m not a urologist, even though they do lots of cool procedures and I’ve always like the phrase “Urologist is my ologist.” Two examples of this phenomena:

Two days ago I got a call from a colleague at another hospital who needed to transfer a patient to our facility. The patient needed to see a colon and rectal surgeon for rectal bleeding. He had rectal bleeding because he was out turkey hunting that morning and needed to move his bowels. When he lowered his trousers to squat, a sharp stick had reportedly penetrated his rectal area. The stick was not there when the patient arrived, of course, but the bleeding was quite severe and the patient genuinely needed specialty care.

I’m taking this report on the phone and being very professional about the whole thing. But after five minutes of “Hmmmm,” and “Yes, I see,” and “Oh, my,” I was about to lose it. All kinds of visions were running through my head; besides I knew that when I was in Boy Scouts, I always looked at where I was putting my nethers in the forest. So I finally said to the doc on the phone “Hey, are you having as much trouble keeping a straight face right about now as I am?”

There was a small chortle, and then a full-fleged laugh.

“It’s been a tough hour of not smiling over here. A really tough hour.”

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The second patient came in with a fractured penis.

(You’re laughing already, and I haven’t even started the story. Let’s try again.)

The second patient came in with a fractured penis. A bit of anatomy here. Although men do get boners, there is actually no bone in the penis. There is a bone in the penis of certain reptiles, which may give rise to the term “Lounge Lizards,” but not in human beings. What causes the penis to rise to attention, besides the attention of a desirable partner (or with enough beer, any partner) is that along the top of the penis there are two cavities called the corpus cavernosa that fill with blood when stimulated. When engorged, the cavities become rigid, and that’s what really causes the male member to demonstrate it’s intent. These rigid chambers have the consistency of Styrofoam; and as anyone who’s dropped a full cooler knows, given enough force of impact Styrofoam will break.

Personally, I think that there are noble and ignoble ways to suffer this kind of injury. The noble way is to be working the hospitality suite at a nymphomanic convention. An ignoble way is to do what this gentleman did, which was to take a rigid plastic penis enlargement pump (see “Austin Powers: International Man of Mystery”), wedge it between two of the cushions on your couch, and simulate a stress-relieving interaction. As you might guess, rigid plastic doesn’t respond particularly well to affection. One wrong move, and the corpus cavernosa go snap.

So this guy has a fractured penis. What you see clinically is a huge bruise and swelling on one side of the penis with the tip pointing at a 90 degree angle in the other direction. There is a small amount of blood coming from the tip of the organ. The real problem with these injuries is not only related to sexual function, but also a possible tear of the urethra, the thin tube that carries urine from the bladder to the external world.

What you need to do to evaluate these injuries is get a retrograde urethrogram, in which you inject a small amount of dye into the tip of the penis and take an X-ray film to make sure the dye stays within the urethra and does not leak out into the surrounding tissues. This is not a routine procedure, so I called the radiologist to make the arrangements. I told him the story. His response was “Really? Can I come see?”

Well, of course he could. It only makes sense for a physician to be able to completely evaluate the patient. So he came down to the ED. He saw the patient, and then motioned me around a corner.

“He was banging a penis pump?”

“Yeah, I think so.”

He looked at me. I looked at him. And we both reverted to eight-year olds, and we both began to snicker.

The urethrogram was negative, but there was still the issue of the fracture. These injuries often need surgery in order to restore normal “position and function,” as it were. So we called the urologist, who came to the ED, saw the patient, motioned the radiologist and myself around a corner, and all three of us began to snicker.

About two months later I was in the Doctor’s Lounge grabbing a soda. The radiologist and I had already been chatting about nothing in particular when the urologist walked in.

“Hey, whatever happened to that guy…you know who I mean.”

He did know. It turns out that the patient had refused surgery despite being told that without operation, his penis would probably heal with a 90 degree bend in it. Useful if you want to pee around corners, but not too good for romance.

4 comments:

OK This is funny but fascinating. And reminds me of a story a friend tells. When he was an older teenager, his Scout troop went skinny dipping out in the woods with their adult leaders (an activity that would be highly frowned upon today but apparently not a big deal 35 years ago). One of the adult leaders snagged this important part of his anatomy on a submerged limb and had to be rushed to the ER. Given the ER staff's fascination with bizarre injuries, I've always figured this must have had the entire staff laughing hysterically.

Ok I was in triage the night the guy got the stick placed in a bad area. Is that REALLY what happened? I just kept thinking that it sounded like a cover story to me. I took the evac call but never followed up with it.